National Fire Fighter NearMiss Reporting System

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National Fire Fighter Near-Miss Reporting System
Near-Miss Reporting Enhancing Firefighter
Safety Through the Lessons of Others Prepared
for 2008 New Mexico Fire Service
Conference Ruidoso, NM May 7, 2008
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Synopsis

• Program Overview 15 minutes
• Website Visit 10 minutes
• The Fort Wayne Indianapolis Experience 10
  minutes
• Putting Near Miss to Work in Your Department (45
  minute Exercise)
• HFACS Overview and Tool 15 minutes
• Case Study Presentation 10 minutes
• Working Group Discussions 20 minutes
• Wrap Up 10 minutes

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Learning Objectives

• Familiarize attendees with
• The benefits of contributing to and using
  www.firefighternearmiss.com.
• Findings from the analysis exercises.

• Provide attendees with
• Examples of how near-miss reporting can be
  implemented in their fire department.
• An opportunity to contribute to an interactive
  discussion that improves firefighter safety.

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Can we keep living with this

• 115
• 2007 Fatalities
• 74 related to emergency incidents
• 48 at fire scene
• 19 caught or trapped
• 54 heart attacks
• 23 vehicle crashes
• (provisional)

• 45
• 2008 Fatalities
• (05/01/2008)
• 1 assault
• 7 caught/trapped
• 1 electrocution
• 1 fall
• 12 heart attack
• 4 struck by
• 10 undetermined
• 9 vehicle crashes

106 2006 Fatalities 61 related to emergency
incidents 36 at fire scene 15
responding/returning 9 in training
activities 20 after on-duty activity 50 heart
attacks. 19 vehicle crashes
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The Fatality Learning Curve
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We have training days
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and Maydays
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dramatic days
9
mundane days that go wrong
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beyond comprehension days.
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How did these incidents happen?

• ERROR!

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Human Factor Error Causes

• Lack of Communication
• Complacency
• Lack of Knowledge
• Distraction
• Lack of Teamwork
• Fatigue

• Lack of Resources
• Pressure
• Lack of Assertiveness
• Stress
• Lack of Awareness
• Norms

Gordon Duponts Dirty Dozen
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What do we do to prevent error?
Use All Resources
Maintain Situational Awareness
Follow SOPs
High Level of Proficiency
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Best efforts still have holes
Use All Resources
Follow SOPs
Maintain Situational Awareness
High Level of Proficiency
James Reasons Swiss Cheese
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When the holes line up
Use All Resources
Follow SOPs
Maintain Situational Awareness
DISASTER!
High Level of Proficiency
James Reasons Swiss Cheese
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Error
James Reason, British Journal of Medicine

• Person approach
• Basic premise unsafe acts arise from
  forgetfulness, inattention, poor motivation,
  carelessness, negligence, and recklessness.
• Focuses on unsafe acts of people at the sharp
  end firefighters, engineers, company officers,
  paramedics, etc.
• Countermeasures reduce unwanted variability in
  human behavior. Invoke corrective measures that
  appeal to peoples sense of fear (disciplinary
  measures, threat of litigation, retraining,
  naming, blaming, and shaming).
• When an adverse event occurs, the important issue
  is who blundered, not why.    

• System approach
• Basic premise humans are fallible, errors are to
  be expected.
• Errors are consequences rather than causes,
  originating "upstream. Include recurrent error
  traps in the workplace and organizational
  processes.
• Countermeasures change the conditions. Create
  system defenses.
• When an adverse event occurs, the important issue
  is not who blundered, but how and why the
  defenses failed.

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When Things Go Wrong . . .
How It Is Now . . .
How It Should Be . . .
You are human
You are highly trained
and
and
Humans make mistakes
If you did as trained, you would not make mistakes
so
so
Lets also explore why the system allowed, or
failed to accommodate your mistake
You werent careful enough
so
and
You should be PUNISHED!
Lets IMPROVE THE SYSTEM!
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Error Management

• Helmreichs Error Management Model

AVOID
TRAP
MITIGATE
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Why Study Near Misses?
1 Tragic Opportunity to learn
1 Serious Accident
300 Survival Stories Opportunities to learn
15 Major Accidents
300 Near Misses
15,000 Observed Worker Errors
- H. W. Heinrich, 1930
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Why Share Near-Miss Experiences?

• Capitalize on kitchen table tradition
• Value in mentoring
• Identify patterns ininjury-producing behaviors

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www.firefighternearmiss.com

• Funding DHS Assistance to Firefighters Grant
  Program.
• Founding funds from Firemans Fund Insurance
  Company.
• 1750 reports to date.
• 100,000 unique visitors.
• 50 states plus Canada are submitting reports.

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All Hazards Reporting System
No statute of limitations on reporting. Reports
reviewed and coded by fire service professionals.
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Features

• Voluntary
• Confidential
• Non-punitive
• Secure
• Web based
• Free

Photo by Jason Henske
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Program Vision
Individual Department Industry
Skill Building
Data Collection Analysis Output
Individual Department Industry
Knowledge Acquisition
Value Development
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• http//www.firefighternearmiss.com/

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Experience of Others
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The Fort Wayne Story
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March 31/April 1 2005

• Pilot City
• Train-The-Trainer
• Hands-on

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April 2005

• Introduced
• the Program
• CRM Binder
• Training CD

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April-May 2005

• Hands On Training (All Companies)
• Distribution Of Posters, Mouse Pads, Pens, etc..

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May-July 2005

• Visit All Fire Stations
• Review System
• Enter Reports
• Pilot Testing

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Fort Wayne Saving Our Own
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The Indianapolis Experience
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The Indianapolis Experience

• Phase One Orientation
• Involvement began in spring of 2005
• Beta test firehouses identified (5)
• One-on-one orientation given to firefighters in
  test firehouses
• Six (6) month evaluation period

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The Indianapolis Experience

• Phase Two Department-wide rollout
• Orientation provided to all members
• Mouse pads, flyers, etc. distributed to
  firehouses
• Report of the Week posted on department web site

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The Indianapolis Experience

• Phase Three County-wide orientation
• Met with departments in Marion County, Indiana
  (12)
• Provided overview of Near-Miss program
• Provided resources for departments

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The Indianapolis Experience

• Results
• Began a critical analysis of near-miss incidents
• Focus on all aspects of a near-miss
• Significant increase in education related to
  near-miss incidents, i.e. How should we respond?

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The Indianapolis Experience

• Results, cont.
• Initial response increased
• We share what we learn

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The Indianapolis Experience

• Case Study January 20, 2008
• IFD companies dispatched to a routine wood
  frame, single family dwelling fire, 1,000 sq.
  ft. (common)
• Response of three engines (one as the RIT), two
  ladders, one squad, and one battalion chief.
• 24 firefighters on initial response.

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The Indianapolis Experience

• Case Study, continued. . .
• Basement fire
• Floor collapse three firefighters fell into
  basement
• Mayday sounded
• All three removed with minor injuries

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The Indianapolis Experience

• Case Study Post Analysis
• Cause origin determined
• Communication records reviewed
• Firefighters interviewed non-punitive

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The Indianapolis Experience

• Case Study Post Analysis
• Focus
• Behavioral aspects
• Equipment
• Training

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The Indianapolis Experience

• Conclusion
• On-going process Flavor-of-the-Month
• Not specific to firefighting, i.e. EMS, rescue,
  etc.
• Requires commitment from senior command staff

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Putting Near Miss to Work

• Case Studies Exercise
• HFACS Tool
• Results

Jason Henske Photo
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HFACS

• Human Factors Analysis and Classification System
• Developed and used by the U.S. Navy to
  investigate accidents.
• Determines level of involvement at all layers of
  the organization.
• Focuses on 4 areas of performance
• Unsafe Acts
• Preconditions to Unsafe Acts
• Unsafe Supervision
• Organizational Influences

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Acts

• Error
• Lack of skill
• Lack of education/training
• Poor decision making
• misperception

• Violation
• Willful
• disregard for
• rules
• regulations

or
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Preconditions to Acts

• Assesses condition of person or people involved
• Focused or distracted
• Hurried
• Physically ill or unfit
• Wrong person for job
• CRM used
• Readiness

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Supervision

• Adequate or inadequate
• Failure to correct
• Planned inappropriate ops
• Effect of freelancing

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Organizational Influences

• Most difficult to assess
• Need to read between
• the lines
• Resources
• Departmental climate
• SOPs (or lack of)

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Analysis Exercise
Ill-defined SOPs Labor/Management Issues Low
Morale
Org. Influences
Task Allocation Failure to Correct Willful
Disregard
Unsafe Supervision
Preconditions
Fatigue Complacency Loss of Situational Awareness
Unsafe Acts
Crew Actions
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Reasons Swiss Cheese
Org. Influences
Latent Conditions
Unsafe Supervision
Preconditions
Active Conditions
Unsafe Acts
DISASTER!
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Analysis Exercise

• Resources
• Departmental climate
• SOPs (or lack of)

Organizational Influences

• Adequate or inadequate
• Failure to correct
• Planned inappropriate ops
• Freelancing

Unsafe Supervision
Preconditions

• Focused or distracted
• Hurried
• Physically ill or unfit
• Wrong person for job
• CRM used
• Readiness

Unsafe Acts

• Error
• Violation

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Case Studies Intersections

• 138 Intersection
• 33 Intersections
• Incursions
• Collisions
• FD driver actions
• Civilian driver actions

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Report Number 05-362

• Demographics
• Department type  Paid Municipal
• Job or rank  Driver / Engineer
• Department shift  24 hours on - 48 hours off
• Age 34 - 42
• Years of fire service experience 11 - 13
• Region FEMA Region VI  
•  

• Event Information
• Event type  Other
• Event date and time 07/25/2005 1330
• Hours into the shift 0 - 4
• Event participation Involved in the event
• Do you think this will happen again? Uncertain
• What do you believe caused the event?
• Situational Awareness
• Individual Action
• Human Error
• What do you believe is the loss potential?
• Life threatening injury
• Property damage
• Lost time injury

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• Event Description
• I was driving an engine company to a reported
  fire with the first in unit reporting "fire
  through the roof" when I approached an
  intersection. Our department policy is to come to
  a complete stop at all red lights and gain
  control of the intersection. My light was red. I
  had sounded both the air horn and the mechanical
  siren. The cross street was a 5 lane street with
  a center turn lane. The traffic on this street
  was stopped in all three lanes to my left. The
  traffic to my right was stopped in the right lane
  and the center turn lane. The middle lane was
  empty. Having slowed to approximately 20-25mph I
  thought I was clear to go when my Lt. screamed
  "STOP-STOP-STOP." I slammed on the brakes just in
  time to stop before crashing into a small sedan
  that had come through the middle lane
•  
• Lessons Learned
• I re-learned to not let the nature of the call
  that I am responding to dictate the way I drive
  or compromise my judgment. I will no longer
  "bust" an intersection.

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CODE 3D Simulation
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Report Analysis

• Resources
• Departmental climate
• SOPs (or lack of)

Organizational Influences
05-362

• Adequate or inadequate
• Failure to correct
• Planned inappropriate ops
• Freelancing

Unsafe Supervision
Preconditions

• Focused or distracted
• Hurried
• Physically ill or unfit
• Wrong person for job
• CRM used
• Readiness

Unsafe Acts

• Error
• Violation

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Report Number 06-534

• Demographics
• Department type  Paid Municipal
• Job or rank  Lieutenant
• Department shift  24 hours on - 24 hours off
• Age 25 - 33
• Years of fire service experience 7 - 10
• Region FEMA Region IV  

• Event Information
• Event type  Vehicle event responding to,
  returning from, routine driving, etc.
• Event date and time 10/26/2006 2000
• Hours into the shift 17 - 20
• Event participation Involved in the event
• Do you think this will happen again? Yes
• What do you believe caused the event?
• Human Error
• Training Issue
• Decision Making
• What do you believe is the loss potential?
• Life threatening injury
• Lost time injury
• Property damage

NIOSH Photo
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• Event Description
• While responding to an automatic fire alarm, my
  engine company was almost struck by another
  engine company at an intersection. My company had
  the right away and the green light. The other
  engine had an inexperienced driver and blew the
  intersection almost hitting a vehicle. This
  vehicle had pulled over for my engine company and
  the truck company that was in front of us. If my
  driver had not stopped before entering the
  intersection, we WOULD have been struck by the
  oncoming engine. The roads were wet and it was
  raining and dark. The other engine company
  personnel were using a reserve pumper that is
  road worthy as a front line apparatus. After
  asking the driver about his actions, he responded
  "I cannot help you are so slow!
•   
• Lessons Learned
• Poor decision making, training, and staffing
  problems all come back to leadership. In the long
  run, someone will pay for it.

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Code 3D Simulation
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Report Analysis
Organizational Influences
?
06-534
Unsafe Supervision
?
Preconditions
Unsafe Acts
?
?
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2007 Analysis

• PPE
• Flashover
• Vehicle Blocking
• Trusses
• Maydays

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2007 Findings
FRI Atlanta
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Root Cause of Event
Human Factors Analysis and Classification System
(HFACS)
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Contributing Factors
all reports submitted
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Contributing Factors-Overlap

• Situational Awareness 508
• Decision Making 252
• Human Error 227
• Individual Action 148
• Communication 102
• Training Issue 91
• Decision Making 456
• Situational Awareness 252
• Human Error 209
• Individual Action 168
• Communication 89
• Command 88
• Human Error 441
• Situational Awareness 227
• Decision Making 209
• Individual Action 162

Individual Action 325 Decision Making 168 Human
Error 162 Situational
Awareness 148 Communication 64 Training
Issue 51 Communication 199 Situational
Awareness 102 Decision Making 89 Human Error
72 Individual Action 64 Accountability
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Wayne Wiggans Photo
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In Your Department

• The question to ask is not,
• How do I know what is going on in my fire
  department?
• (Reactive)
• but
• How do I use the program to benefit my
  department?
• (Proactive)

Photo by Bob Bartosz
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Reactive

• Searching the database trying to find what near
  miss took place in your FD.

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Proactive

• Search reports by your departments profile.
• Training/Safety officers can use the grouped
  reports found on the resources page.
• Empower every firefighter to submit reports.
• What processes are in place to prevent
• a near-miss from occurring?

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Incentives for Reporting

• Intangibles
• Less fear of reprisal.
• Improved morale.
• Work force more accepting of discipline when it
  occurs.
• The Altruism Factor

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What can Near Miss do for you?

• Provide case studies to enhance learning.
• Provide data to enhance drill development.
• Serve as a research site for students to use as a
  resource.

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What can you do for Near Miss?

• Visit the site at the beginning of each shift.
• Submit reports promptly.
• Add www.firefighternearmiss.com to My
  Favorites.
• Encourage firefighters to submit reports and use
  the system.
• Subscribe to Report of the Week.

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Report of the Week

• Weekly e-mail containing featured report and
  follow-up questions
• Provides ready-made kitchen table drill
• E-mail list has grown to 6500 with a forward to
  over 50,000

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Recap

• Does Near-Miss Reporting have a place in your
  fire department?
• Value added benefit?
• Obstacles?
• Solutions?

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Founding Partners
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Friend of Program

• www.FirefighterCloseCalls.com
• in mutual dedication to fire fighter safety and
  survival.

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National Fallen Firefighters Foundation
Supports Life Safety Initiatives

• Directly supports
• 1 Culture Change toward safer service
• 7 Research Data collection
• 8 Using Technology to promote safety
• 9 Investigate NMs

• Indirectly supports
• 2 Enhancing accountability
• 3 Integrating incident risk management
• 4 Empowering firefighters to speak up

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Endorsements

• International Society of Fire Service Instructors
• Fire Department Safety Officers Association
• IAFC Eastern Division
• IAFC Safety, Health Survival Section
• Numerous fire departments individual
  firefighters

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Fire-Rescue International 2008Denver, Colorado
Tuesday, August 12 Wednesday, August 13 FREE
Pre-Con Workshop Friday, August 15 Battalion
Chief Case Studies Friday, August 15-Saturday,
August 16 Booth Open on Exhibit Floor Saturday,
August 16 Presentation The Pennsylvania Story
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Near-Miss Award

• Funded by ISFSI.
• Department that best demonstrates how it
  incorporates near-miss reporting into their
  department.
• 500 words or less.
• Due date July 11, 2008
• Presentation FRI/Denver 2008.

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Contact Information

• John Tippett
• john.tippett_at_montgomerycountymd.gov
• or
• jtippett_at_iafc.org
• 240-832-6563

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• QUESTIONS?